5. Aneurism may be coexistent, however, and therefore it may sometimes be advisable to make an exploratory capillary puncture before opening the chest freely.
Berard reports a case of empyema which formed a tumor on the left side of the sternum, which pulsated and looked like an aneurism. Finally, the tumor burst and discharged pus.
DURATION.—The progress of aneurism of the aorta is very rapid, and in the majority of cases the fatal termination is not delayed many months. In 40 cases where the duration of the disease was well defined, I found that 20 of them died within one year, 9 lived for two years, and 3 lingered five years. About 75 per cent., therefore, died within two years.
TERMINATION.—Rupture of the sac is a frequent cause of death. In 106 cases analyzed by me, 39 terminated in this manner. The seat of the rupture and the organs into which the blood escapes vary according to the location of the sac.
Aneurisms of the ascending aorta burst most frequently into the pericardium, right auricle, right ventricle, right pulmonary artery, and rarely externally. Tumors of the transverse portion burst into the trachea, left lung and left bronchi, left pleural cavity, oesophagus, and externally. Those of the descending aorta empty into the oesophagus, left pleural cavity, and spinal cord.
The most frequent point of rupture appears to be into the pericardium, as 13 out of 39 ruptures emptied into that cavity. It will also be noticed that the right side of the heart and the left pleura and lung are the chosen seats of hemorrhage. I found no case of rupture into the left side of the heart.
The bursting of an aneurism is not always an immediately fatal accident. The so-called weeping aneurism may pour forth small amounts of blood for weeks and months. Neligan reports a case of external rupture near the second rib on the right side which discharged blood at intervals for more than a year. At times the bleeding was with difficulty arrested, and yet the aneurism finally solidified and the patient left the hospital calling himself well. Another man with an external aneurism thought it was a blood-boil, and squeezed it with his chin to favor the flow until he fainted. The bleeding then ceased, and never occurred again. He died one year later of typhoid fever. Such cases, however, are very rare, and usually when an aneurism bursts externally the death is sudden and tragic.
Rupture of a sac into the pericardium or pleural cavity may not prove fatal for several hours, and the patient will exhibit the ordinary symptoms of internal hemorrhage. Rupture into the heart or pulmonary artery causes great dyspnoea and distress, and death follows rapidly.
Aneurism may cause death indirectly by starvation from pressure on the oesophagus, or by suffocation from occlusion of the trachea. The pain and distress occasioned by the tumor may cause death from exhaustion. Pain at times is so great that the sufferers can neither lie down nor stand, and, deprived of rest and food, they wear out. A few patients die from intercurrent accidental diseases or complications, but it may justly be said that the death of a patient with aneurism is usually directly referable to the tumor itself.
TREATMENT.—Aneurisms of the aorta occasionally solidify by the formation of a clot, and thus a spontaneous cure is established. Unfortunately, however, such a result is a rare exception to the rule of steady progress to death.